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Prevention of Ventilator Associated Events - Adult - Inpatient

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1
Prevention of Ventilator Associated
Events (VAE) – Adult – Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
METHODOLOGY ...................................................................................................................... 4
DEFINITIONS ............................................................................................................................ 5
INTRODUCTION ....................................................................................................................... 6
RECOMMENDATIONS .............................................................................................................. 6
Strategies to Detect VAE ..................................................................................................................... 6
Provider Responsibilities ..................................................................................................................... 6
Nursing Responsibilities ...................................................................................................................... 7
Nursing Assistant Responsibilities ...................................................................................................... 7
Respiratory Therapy Responsibilities .................................................................................................. 7
UW HEALTH IMPLEMENTATION ............................................................................................. 8
APPENDIX A. EVIDENCE GRADING SCHEMES ..................................................................... 9
REFERENCES .........................................................................................................................11
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2
CPG Contact for Content:
Name: Michelle Schmitz, CIC – Infection Control
Phone Number: (608) 263-7242
Email Address: mschmitz@uwhealth.org

Names: Sarah Van Hoof, BSN, RN- Infection Control
Phone Number: (608) 440-6378
Email Address: svanhoof@uwhealth.org

CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org

Coordinating Team Members:
Nasia Safdar, MD- Medicine- Infectious Disease
Pierre Kory, MD- Critical Care Service
Joshua Medow, MD, MS, FAANS, FACS- Neurological Surgery- General
Anna Krupp, CNS- Trauma Life Support Center
Margaret Murray, CNS- Cardiothoracic Surgery
Patricia Chesmore- Nursing- Neuro ICU
Kris Ostrander, RT- Respiratory Therapy
Stephanie Kraus, CNS - Cardiology

Review Individuals/Bodies:
Philip Trapskin – Pharmacy Manager

Committee Approvals/Dates:
Critical Care Committee (01/28/16)
Clinical Knowledge Management (CKM) Council (01/28/16)

Release Date: March 2016 | Next Review Date: March 2018















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3
Executive Summary
Guideline Overview
This CPG is to provide an evidence-based guideline for inpatient management of adult patients
requiring continuous invasive ventilation via endotracheal tube or tracheostomy for the
prevention of VAE.

Key Practice Recommendations
1. Use noninvasive ventilation whenever possible.
2. Minimize duration of ventilation.
3. Avoid unplanned extubation and reintubation.
4. Avoid gastric over distention.
5. Orotracheal intubation is preferable to nasotracheal intubation.
6. Administer GI prophylaxis medications as indicated. Maintain patients in a semi recumbent
position (30-45) unless there are contraindications.
7. Perform oral care every 4 hours with an antiseptic solution for all patients receiving
continuous ventilation.
a. Administer chlorhexidine 0.12% oral care to patients orally intubated.
b. Oral care performed before patient transfer from the unit.
8. Perform daily sedation interruption assessment (spontaneous awakening trails) when
indicated
9. Replace the oral suction catheter, canister and tubing every 24 hours.
10. Maintain an endotracheal cuff pressure to minimal occlusion volume.
11. Perform cuff pressure checks twice daily and before and after each patient transfer from the
unit; monitor the ETT for movement before and after patient transfer from unit
12. Implement strategies to minimize contamination of equipment used to care for patients
receiving mechanical ventilation.
13. Perform daily assessments of readiness to wean ventilation and use unit-specific weaning
protocols.
14. Clean high touch surface on respiratory equipment once per day
15. Change the resuscitation bag once a month or when visibly soiled.
Ventilator circuit should be changed every month or when visibly soiled.
16. Optimize antimicrobial therapy in the treatment of pneumonia to reduce ventilator days.

Companion Documents
1. Adult Critical Care Weaning Algorithm
2. Cardiology Adult Ventilator Weaning
3. Pain, Agitation and Delirium in Mechanically Ventilated ICU Patients – Adult – Inpatient
Clinical Practice Guideline
4. Guidelines for the Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-
lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram-Negative Infections
– Adult – Inpatient Clinical Practice Guideline







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4
Scope
Disease/Condition(s): Patients requiring continuous invasive ventilation via endotracheal tube
or tracheostomy for the prevention of ventilator associated event (VAE).

Clinical Specialty: Critical Care, Intermediate Care, Infection Control, Pharmacy, Respiratory
Therapy

Intended Users: Physicians, Advanced Practice Providers, Nursing and Respiratory
Therapists, Pharmacists

Objective(s): To provide evidence-based guidelines for inpatient management of adult patients
requiring continuous invasive ventilation via endotracheal tube or tracheostomy for the
prevention of VAE.

Target Population: Adult inpatients (18 years or older) requiring continuous invasive ventilation
via endotracheal tube or tracheostomy for the prevention of VAE

Interventions and Practices Considered:
• Strategies to detect VAE
• Strategies to prevent VAE
o General strategies
o Strategies to prevent aspiration
o Strategies to reduce colonization of the oropharyngeal cavity

Major Outcomes Considered: Provide evidence-based, quality and safe care to adult
inpatients requiring continuous invasive ventilation for the prevention of VAE.
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (i.e., PUBMED) were conducted by the workgroup members to
collect evidence for review. Expert opinion, clinical experience, and regard for patient
safety/experience were also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The interdisciplinary workgroup members agreed to adopt recommendations developed by
external organizations or developed internally derived recommendations. All recommendations
were derived by establishing group consensus through discussion of the literature evidence and
expert/institutional experiences.

Methods Used to Assess the Quality and Strength of the Evidence/Recommendations:
Recommendations developed by external organizations, such as the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) or
Centers for Disease Control and Prevention (CDC), maintained the evidence grades assigned
within the original document and were adopted for use at UW Health.

Recommendations developed internally, based upon literature evidence or clinical experience
evaluated during the workgroup meetings, were evaluated using the Grading of
Recommendations Assessment, Development and Evaluation (GRADE) scheme (Figure 1 of
Appendix A).

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5
Definitions
Ventilator Associated Events (VAEs) are identified by using a combination of objective
criteria:
• Deterioration in respiratory status after a period of stability or improvement on the
ventilator
• Evidence of infection or inflammation, and
• Laboratory evidence of respiratory infection.
• Patients must be mechanically ventilated for more than 2 calendar days to be eligible for
VAE.

Ventilator: A device to assist or control respiration continuously, inclusive of the weaning
period, through a tracheostomy or by endotracheal intubation.

Episode of mechanical ventilation: Defined as a period of days during which the patient was
mechanically ventilated for some portion of each consecutive day.

Ventilator-Associated Condition (VAC)
• Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2
calendar days of stable or decreasing daily minimum* FiO2 or PEEP values AND
• Increase in daily minimum* FiO2 of ≥ 0.20 (20 points) over the daily minimum FiO2 in
the baseline period, sustained for ≥ 2 calendar days AND/OR
• Increase in daily minimum* PEEP values of ≥ 3 cmH2O over the daily minimum PEEP in
the baseline period†, sustained for ≥ 2 calendar days.

Infection-related Ventilator-Associated Complication (IVAC)
• Patient meets criteria for VAC AND
• Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤
4,000 cells/mm3. AND
• A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days.

Possible Ventilator-Associated Pneumonia (PVAP)
• Patient meets criteria for VAC and IVAC AND
• New positive culture of one of the following specimens without requirement for purulent
respiratory secretions:
o Endotracheal aspirate, ≥ 105 CFU/ml or corresponding semi-quantitative result
o Bronchoalveolar lavage, ≥ 104 CFU/ml or corresponding semi-quantitative result
o Lung tissue, ≥ 104 CFU/g or corresponding semi-quantitative result
o Protected specimen brush, ≥ 103 CFU/ml or corresponding semi-quantitative
result
• Purulent respiratory secretions plus a positive culture of one of the following specimens
(qualitative culture, or quantitative/semi-quantitative culture without sufficient growth to
meet criterion #1): •
o Sputum
o Endotracheal aspirate
o Bronchoalveolar lavage
o Lung tissue
o Protected specimen brush
• One of the following positive tests:
o Pleural fluid culture
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6
o Lung histopathology,
o Diagnostic test for Legionella species
o Diagnostic test on respiratory secretions for influenza virus, respiratory syncytial
virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus,
coronavirus
Introduction
Mechanical ventilation is an essential, life-saving therapy for patients with critical illness and
respiratory failure. Studies have estimated that more than 300,000 patients receive mechanical
ventilation in the United States each year. These patients are at high risk for complications and
poor outcomes including death. Ventilator-associated pneumonia is one of the complications
that can occur in patients receiving mechanical ventilation. Such complications can lead to
longer duration of mechanical ventilation, longer stays in the ICU and hospital, increased
healthcare costs, and increased risk of disability and death.
Recommendations
Strategies to Detect VAE
Surveillance definition: Patients must be mechanically ventilated for more than 2 calendar days
to be eligible for VAE. The VAE definition was developed by the CDC, National Health and
Safety Network (NHSN) Protocol for Ventilator Associated Events, July 2013. (SHEA/IDSA Rating
A-I)

Ventilator Associated Events (VAE) is identified by using a combination of objective criteria:
• Deterioration in respiratory status after a period of stability or improvement on the
ventilator,
• Evidence of infection or inflammation, and
• Laboratory evidence of respiratory infection.
Methods for Surveillance
1. Active surveillance is used to identify patients with possible VAE using an electronic
surveillance system and Health Link clarity reports.
2. Conduct continuous active surveillance for VAE through the Infection Control Department.
(SHEA/IDSA Rating A-II)
General Strategies
1. Adhere to hand-hygiene guidelines published by the CDC and UWHC Policy #13.08 Hand
Hygiene. (CDC Category IA)
2. Use noninvasive ventilation whenever possible. (SHEA/IDSA Rating B-III)
3. Minimize duration of ventilation. (SHEA/IDSA Rating B-II)
4. Avoid unplanned extubation and reintubation. (CDC Category II)
Provider Responsibilities
1. Avoid gastric over distention. (UW Health Moderate quality evidence, SHEA/IDSA Rating II)
2. Orotracheal intubation is preferable to nasotracheal intubation. (CDC Category IB)
3. Follow the UW Health Stress Ulcer Prophylaxis – Adult and Pediatric – Inpatient – Clinical
Practice Guideline for management of stress ulcers.
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7
Nursing Responsibilities
1. Maintain patients in a semi recumbent position (30-45) unless there are contraindications.
(SHEA/IDSA Rating B-II)
2. Perform regular oral care with an antiseptic solution for all patients receiving continuous
ventilation, reference UWHC Departmental Policies #7.11 and #7.19. (SHEA/IDSA Rating A-I)
a. Evaluate the patient for contraindications for every 4 hour oral care (e.g. oral
trauma, oral bleeding, or physician order).
3. Replace the oral suction catheter every 24 hours. (UW Health Very low quality evidence, strong
recommendation)
4. Perform regular early mobilization using unit-specific mobility protocols.
5. Perform regular assessment and interventions for managing pain, agitation and delirium.
(UW Health High quality evidence, SHEA/IDSA Category I)
Nursing Assistant Responsibilities
1. Replace the oral suction canister and tubing every 24 hours. (UW Health Very low quality
evidence, strong recommendation)
2. Replace in-line suction canisters and tubing every 24 hours. (UW Health Very low quality
evidence, strong recommendation)
Respiratory Therapy Responsibilities
1. Maintain an endotracheal cuff pressure to minimal occlusion volume. Perform cuff pressure
checks daily and before and after each patient transfer from the unit. (UW Health Very low
quality evidence, strong recommendation)
2. Strategies to minimize contamination of equipment used to care for patients receiving
mechanical ventilation
a. Use sterile water to rinse reusable suction equipment, such as yankauer.
(SHEA/IDSA Rating I-B)
b. Replace in-line suction catheters every 24 hours. (UW Health Very low quality
evidence, strong recommendation)
3. Perform daily assessments of readiness to wean ventilation and use unit-specific weaning
protocols. (SHEA/IDSA Rating A-II)
a. Document the evaluation on the mechanical ventilation sheet.
4. Clean high touch surface on respiratory equipment every 24 hours.
5. Change the resuscitation bag once a month or when visibly soiled.
6. Ventilator circuit should be changed every month or when visibly soiled. (UW Health High
quality evidence, strong recommendation)

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8
UW Health Implementation
Potential Benefits:
Establishment of effective and consistent methods to detect, prevent, and treat VAEs in adults.

Potential Harms:
Complications, such as pneumonia, may develop in patients receiving mechanical ventilation.

Pertinent UW Health Policies & Procedures
1. UWHC Nursing Policy #7.19 Care of the Patient with a Tracheostomy Tube, Adult and Pediatric
2. UWHC Policy #13.08 Hand Hygiene
3. UWHC Respiratory Therapy Policy #2.02 Mechanical Ventilation Adult and Pediatric
4. UWHC Respiratory Therapy Policy #3.55 Blind Bronchoalveolar Lavage or Non-Bronchoscopic BAL
5. UWHC Respiratory Therapy Policy #1.53 Respiratory Care Protocol

Patient Resources
1. HFFY #4310: Trauma and Life Support Center- A Guide for Patient and Family
2. HFFY #4437: Ventilators
3. HFFY #7282: Keeping Your Family Member Safe While On A Ventilator
4. HFFY #6337: Intubation and Mechanical Ventilation in the ICU

Guideline Metrics: Mechanisms to capture immediate compliance to prevention VAE prevention
strategies are being explored through the use of unit dashboard technology and clarity report writing.
Current strategies to capture guidelines metrics include:
• % of patients with oral care performed
• % of patients with a VAE and these measures completed from start of mechanical ventilation to
date of VAE.
o Oral Care Q4hrs
o CHG Oral Care w/teeth brushing 2X/day
o Head of Bed Elevation > 30 degrees
o Daily Ventilator Weaning Assessment
• Number of patients eligible for spontaneous awakening/breathing trials

Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or equivalent
tools, including:

Order Panel
Mechanical Ventilation- Adult [O117146]

Practice Protocols
Pain, Agitation and Delirium Continuous Infusion Titration – Adult – Inpatient [1]
Spontaneous Awakening Trial (SAT) Practice Protocol – Adult – Inpatient [2]

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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9
Appendix A. Evidence Grading Schemes
RATING SCHEME FOR GRADING OF RECOMMENDATIONS ASSESSMENT,
DEVELOPMENT AND EVALUATION (GRADE)

Figure 1. GRADE Algorithm

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations
Strong for using/Strong against using
The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak for using/ Weak against using
The evidence is weak or the balance of positive and
negative effects is vague.

RATING SCHEME FOR SOCIETY FOR HEALTHCARE EPIDEMIOLOGY OF
AMERICA (SHEA/IDSA)

SHEA/IDSA Quality of Evidence
I Evidence from 1 properly randomized, controlled trial
II Evidence from 1 well-designed clinical trial, without randomization; from cohort or
case-control analytic studies (preferably from > 1 center); from multiple time series;
or from dramatic results from uncontrolled experiments.
III Evidence from opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees.

SHEA/IDSA Strength of the Recommendation
A Good evidence to support a recommendation for use
B Moderate evidence to support a recommendation for use
C Poor evidence to support a recommendation


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RATING SCHEME FOR CENTERS FOR DISEASE CONTROL AND PREVENTION
(CDC)

CDC Categories of Evidence
Category IA
Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical or
epidemiologic studies
Category IB
Strongly recommended for implementation and supported by
some clinical or epidemiologic studies and by strong theoretical
rationale
Category IC
Required implementation, as mandated by federal or state
regulation or standard
Category II
Suggested for implementation and supported by suggestive
clinical or epidemiologic studies or by strong theoretical
rationale
No
Recommendation;
Unresolved Issue
Practices for which insufficient evidence or no consensus exists
about efficacy


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11
References
1. 5 Million Lives Campaign. Getting Started Kit: Prevent Ventilator-Associated Pneumonia How-to
Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available at www.ihi.org)

2. Babcock HM, Zack JE, Garrison T, et al. An educational intervention to reduce ventilator‐associated
pneumonia in an integrated health system: a comparison of effects. Chest 2004; 125:2224-2231.

3. Bergmans DC, Bonten MJ, Gaillard CA, et al. Prevention of ventilator‐associated pneumonia by oral
decontamination: a prospective, randomized, double‐blind, placebo‐controlled study. Am J Respir Crit
Care Med 2001; 164:382‐388.

4. Blackwood B, Alderdice F, Burns KE, Cardwell CR, Lavery GG, O'Halloran P. Protocolized vs. non-
protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients:
Cochrane review protocol, Journal of Advanced Nursing 2009; 65(5):957-64.

5. Bumroongkit C, Liwsrisakun C, Deesomchok A, Theerakittikul T, Pothirat C. Efficacy of weaning
protocol in medical intensive care unit of tertiary care center. Journal of Medical Association Thai,
2005; 88(1):52-7.

6. Centers for Disease Control and Prevention, Guidelines for preventing health-care-associated
pneumonia, 2003; recommendations of CDC and the Healthcare Infection Control Practices Advisory
Committee, MMWR 2004; 53(No. RR-3):1-36.

7. Centers for Disease Control and Prevention, National Health and Safety Network, surveillance
definition of ventilator associated events, July 2013
8. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in
mechanically ventilated adults: systematic review and meta‐analysis. BMJ 2007; 334:889.

9. Chlebicki M, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: A
meta-analysis. Crit Care Med 2007; 35:595-602.

10. Chittawatanarat K, Thongchai C. Spontaneous breathing trial with low pressure support protocol for
weaning respirator in surgical ICU. Journal of Medical Association Thai, 2009. 92(10): 1306-12.

11. Coffin, SE, Klompas M, Classen, D, et al. Strategies to prevent ventilator-associated
12. pneumonia in acute care hospitals, Infection Control and Hospital Epidemiology 2008; 29:S31-S40.

13. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for
preventing ventilator‐associated pneumonia: a meta‐analysis. Am J Med 2005; 118:11-18.

14. Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health
care-associated pneumonia: Underappreciated risk and a call for interventions. Am J Infection Control
2005; 33:527-541.

15. Girault C, Daudenthun I, Chevron V, Tamion F, Leroy J, Bonmarchand G. Noninvasive ventilation as
a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective,
randomized controlled study. American Journal of Respiratory Critical Care Medicine, 1999; 160(1):
86-92.

16. Greene, L, Sposato, K. Guide to the Elimination of Ventilator-Assocaited Pneumonia. Washington,
DC: Association for Professionals in Infection Control and Epidemiology; 2009.

17. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12%
chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients
undergoing heart surgery. Am J Crit Care 2002; 11:567‐570.
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2016CCKM@uwhealth.org



12

18. Klompas, M, Branson, R, Eichenwald, E, et al. Strategies to prevent ventilator-assocaited pneumonia
in acute hospitals: 2014 update. Infection Control Hosp Epidemiol. 2014; 35: 915-936.

19. Koeman M, van der Ven A, Hak E, Joore H, Kaajager K, de Smet A, Ramsay G, Dormans T, Aarts L,
de Bel E, Hustinx W, van der Tweel I, Hoepelman A, Bonten M. Oral decontamination with
chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med
2006; 173:1348-1355.

20. Kollef MH, Shapiro SD, Silver P, St John RE, Prentice D, Sauer S, Ahrens TS, Shannon W, Baker-
Clinkscale D. A randomized, controlled trial of protocol-directed versus physician-directed weaning
from mechanical ventilation. Critical Care Medicine 1997; (4):567-74.

21. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of
ventilator‐associated pneumonia in ICU populations. Intensive Care Med 2006; 32:230-236.

22. Saura P, Blanch L, Mestre J, Vallés J, Artigas A, Fernández R. Clinical consequences of the
implementation of a weaning protocol. Intensive Care Medicine 1996; 22(10):1052-6.
23. Scott, JM and Vollman, KM (2005). Endotracheal tube and oral care. In DJ Lynn-McHale Wiegand &
KK Carlson (Eds.), AACN procedure manual for critical care. (5th ed., pp. 28-33). Philadelphia, PA:
Elsevier Saunders.

24. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial
infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with
chlorhexidine gluconate: a randomized controlled trial. JAMA 2006; 296:2460‐2466.

25. Silvestri L, van Saene JJ, van Saene HK, Weir I. Topical chlorhexidine and ventilator‐associated
pneumonia. Crit Care Med 2007; 35:2468.

26. Randolph AG, Wypij D, Venkataraman ST, Hanson JH, Gedeit RG, Meert KL, Luckett PM, Forbes P,
Lilley M, Thompson J, Cheifetz IM, Hibberd P, Wetzel R, Cox PN, Arnold JH; Pediatric Acute Lung
Injury and Sepsis Investigators (PALISI) Network. Effect of mechanical ventilator weaning protocols
on respiratory outcomes in infants and children: a randomized controlled trial. JAMA 2002;
288(20):2561-8.

27. Tanios MA, Nevins ML, Hendra KP, Cardinal P, Allan JE, Naumova EN, Epstein SK. A randomized,
controlled trial of the role of weaning predictors in clinical decision making. Critical Care Medicine
2006; (10):2530-5.

28. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and
meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-
associated pneumonia. Infection Control and Hospital Epidemiology 2008; 29:131-136.

29. Tonnelier JM, Prat G, Le Gal G, Gut-Gobert C, Renault A, Boles JM, L'Her E. Impact of a nurses'
protocol-directed weaning procedure on outcomes in patients undergoing mechanical ventilation for
longer than 48 hours: a prospective cohort study with a matched historical control group. Critical Care
2005; 9:R83-9. Epub 2005 Jan 17.
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